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Request For Payment

This document is a request for payment from the Mauban District Hospital in Quezon, Philippines. It lists the patient's name and admission/discharge dates, as well as line items for medicines, oxygen, medical supplies, laboratory tests, procedures, fees, and donations. The total amount owed is noted at the bottom. The request is prepared by the pharmacist and noted by the billing clerk.

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KC Palattao
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55 views1 page

Request For Payment

This document is a request for payment from the Mauban District Hospital in Quezon, Philippines. It lists the patient's name and admission/discharge dates, as well as line items for medicines, oxygen, medical supplies, laboratory tests, procedures, fees, and donations. The total amount owed is noted at the bottom. The request is prepared by the pharmacist and noted by the billing clerk.

Uploaded by

KC Palattao
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Republic of the Philippines Provincial Government of Quezon

Provincial Government of Quezon MAUBAN DISTRICT HOSPITAL


MAUBAN DISTRICT HOSPITAL Mauban, Quezon
Mauban, Quezon
REQUEST FOR PAYMENT
REQUEST FOR PAYMENT
Patient’s Name: _________________________________________
Patient’s Name: _________________________________________ Date Admitted: ___________ Date Discharged: __________
Date Admitted: ___________ Date Discharged: __________ ◻ General ◻ Pay ◻ Medicare ◻ OPD
◻ General ◻ Pay ◻ Medicare ◻ OPD
Medicines (RF: ________ CS :_______).................Php
Medicines (RF: ________ CS :_______).................Php Oxygen fee…………………………………………………. _________
Oxygen fee…………………………………………………. _________
Medical supplies (RF: ________ CS :_______)………….._________
Medical supplies (RF: ________ CS :_______)………….._________ _________
_________ Laboratory (Diagnostics)………………………………….... _________
Laboratory (Diagnostics)………………………………….... _________ ECG……………………………………………………….... _________
ECG……………………………………………………….... _________ X-Ray……………………………………………………….. _________
X-Ray……………………………………………………….. _________ OR/DR fee………………………………………………….. _________
OR/DR fee………………………………………………….. _________ Birth/Death Certificate…………………………………………… _________
Birth/Death Certificate…………………………………………… _________ Room and board…………………………………………….. _________
Room and board…………………………………………….. _________ Doctor’s fee…………………………………………………… _________
Doctor’s fee…………………………………………………… _________ Miscellaneous………………………………………………. _________
Miscellaneous………………………………………………. _________ Donation……………………………………………………… __________
Donation……………………………………………………… __________ Others………………………………………………………… __________
Others………………………………………………………… __________
TOTAL
TOTAL Noted by
Noted by
JENNYLYN Q. ERANDIO
JENNYLYN Q. ERANDIO Billing Clerk
Billing Clerk
Prepared by
Prepared by
RELMA S. VILLABROZA/ YSABELLA S. VILLABROZA
RELMA S. VILLABROZA/ YSABELLA S. VILLABROZA Pharmacist
Pharmacist
Republic of the Philippines

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